HomeMy Public PortalAbout5940, 5942, 5944 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875
(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that o have a certificate of consent self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING
pCORESS .[� G�C A /
Certified copy is hereby furnished. nc nR EssVAW LOCALITY
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST �� DISTRICT NO. GROUP TYPE P ESSED BY
CROSS ST. AAV
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL L,O
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAr STATE MAJOR SECOND LOCAL
NO. (CIRCLET
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF 2
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws. MAIL S ® OCCUPANCY GROUP a
U
Date ADDRESS Applicant ,�y— LI.I
NOTICE TO APPLICANT: If,after making this Certificate of CITY �l LE C/ ! NO. OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth-
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION X
Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. C �L•� t �i� L� PARKING
SPACES REO'D D PROVIDED
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a PROM: TOS
licensed architect or a registered professional engineer SIZE OFNO.OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus' EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). 1:'(NAL PRESENT USE OF BUILDING APPROVAL
Lic.or Reg.No. Date
1J,41R 54NO FEE
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi `�� f 4/93ness and Professions Code): NO. PARKING
❑ I, as owner of the property, will do the work and the SPACES PROVIDED 8491 1 PIN '2:20structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILOING
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE 2
upon the above-mentioned property for inspect'•n purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
y
Signature of Permittee Date
\1'UIt1;IRS'('OMP[:NS1TIOtiDL'('L.11t.\TIOX t 1 aar
E_87�fi 4
dMISCELLANEOUS APPLICATION
vie
I he:elly affirm that 1 have a certificate of consent to self
insure. or a certificate of\Porkers'Compensation Insurance.or COUNTY OF LOS .a.!��CFEL�$ BUILDING AND SAFETY DIVISION
III a certified copy thereof iSec.3800.Lab.C.1. `
Policy No. _Conivan} FOR APPLICANT TO FILL-IN BU iLDING
Ar DRESS
Certified copy is hereby furnished. eu1LDING rr
g ADDRESS I�Q LO t_A LITY
I I Certified copy is filed with the county buildine Inspection I OCALITY NEAREST
department. j temple City CF:,OSS ST.
Date__Applicant NEAREST 7 STR IC GR p TYPE P CESSED BY
CRO55 ST. CONST.
CERflFICATL•'OF EXEMPTiON FROM WORKERS' I LEGAL t—
I
COMPENSATION INSURANl!- SCRIPT:ON LOT NO. !BLOCK IMAM NIGNw Av STATE MAJOR SECOND LOCAL
� NO, (CIRCLE)
NO. OF BLDGS.
Mlis section need not he enmpleted if the work involved {I RACT NOW ON LOT USI= ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ISi001 or less.! t usE OF
r 1
Pu OF LOT I EXISTING BLDG. I ,
I certify that in :Ile performance of -Ile work 'or which •his ll� uTg n
permit is issued. I ;(anal :lot employ an} ne:so:l :n am manner OWNER 1. reg Jackson
i
so as to become ;uhiect :o the 1Par ens i :npcnsa[ien 1. rs. OCCUPANCY GROUP —� —
AaIL � n
IJADDRE55 4
Date�_L<' •applicant _ -_
NOTICE To APPLICANT: it•if-c- makinc :!:is i ;Iffierfr c gj r_,T —F .laIL►(o2 OCCUP4N-LOAC
Exemption. you dimild beL•ome subiect :o -lie t\IR'ers
Compewrion provisions of-he Labor-.'.)de. you mus[ torch ILPDL!CATICN °�F .X 44RC!t!•1r E
1 with comniv wirli ouch nrovis:oir; .or his ^craps ;hall he n —
II-RAILER USE iEO LJ GY :NFPE TIC 1 No Soec. <ncC ji, II
deemed:III,;e,i. —
LICENSED CONTRACTORS DECLARATION
OCCUPANCY IN-SPECTION$$ Pan;c Dev;r:es ❑
1 hereby :Iitirnl :Ir:I[ I alp Ilcensed lander previ<lons of Chapter I SAFET PERMIIT LIST ITEMS BELONi
C 1 9 iconin;encine with Section -0001 of Division 3 .ii:he Susi- ` -- NO. OF EXITS
I
Hess and P-ol'cssion.Code.and mylicence !. in .'fail force and -
El
effect. PARKING REO'D I I PROVIDED
y � SPa CES �J
0
License Number_ Lic. Class LIMITED TIME USE
LL �
w Contractor ...-. _--.---._...- Il:ite -._-- - DATE DA TIi
W
l and exempt from the :icensine -edulrenientc :Is 1 am .I
a I licensed architect .r a registered professional engineer I'=1zE DF I No, o� INSPECTOR'S
-I1C �y-XISTING SLOG. STORIE7 SIGN ATU
z acrim_ in any prcf:!;ional :ata it; �a:ria:r 1. 13u;- _ _
a iness and l':ofessicn%Code I.
RESENT USE OF BUILDING F i t L APPROVAL
— ------ ! ---
^
Lic.or Ree. No. ---------- Dae— —--- '�
x ( I
HOME OWNHI-BUILDER DECLARA110N NO. OF EXISTING BUILDINGS �
I
ON LOT AND USE
I hereby af:irin that 1 alp exempt from the Contractor's l
I License Law for the following reason (Section -031.5. Busi-
ness and Professions Code): NO. PARKING
I, as owner of the pproperty. will du theworkork And tile SPACES PROVIDEDe !!
structure is not intended or offered for tale (Section f
1 704.1.Business and Professions Code). I
1 ItIPR OPOSED USE OF BUILDING ad ��
CONSTRUCTION LENDING AGENC)I k,
I hereby affirm that there is a construction lendinu :wcnc% flrIA4-6 OS �p �Q
1 for the performance of the work for which this permit is -.
issued(Sec. 3097•Cie.C.1. 1! 3 S iOnS ilt� `'I `"
Lender's Name.. ----_—._-• � '�' I=-•J I�
�1 r to LSI
& OPOSED MAX. OCC.
Lender's:Address
CD
I I certify that l have read this application and state that the PERM( FEE 25.0 V
above information is correct.1 aeree to comply with all County ISSUANCE FEE 1- �
ordinances and State laws relating to building construction, j• Y
and hereby authorize representatives of this County to enter TOTAL FEE 25.00
1 I upon the above-mentioned property for inspection purposes, l '-
SEE REVERSE I-OR EXPLANATORI' LANGUAGE r...!
Sienatllrc rf Permittee D:atc 10
r ! =c• •G
I
"`"R!:'.1(s'`'°"IPCNSA'rlUN DECLARATION ,�113nt444 MISCELLANEOUS APPLICATION ,
E 137s(11-84)
lereby affirm that t have a certificate of consent to self COUNTY OF LOS ANGELES MK 1
insure, or a certificate of Workers'Compensationlnsurance,ler k , ._. 130ILDING ANI) SAFETY DIVISION
a certified copy thereof(Sec. 3800,Lab.C.). }
i'aatiLy No. ...... .._ t':anlp:lny.._ FOR APPLICANT TO FILL IN BAAU'LarNc
D DRES
ElCertified copy is hereby furnished. BUILDING
Xk ADDRESS 5944 N. TEMPLE CITY BLVD. LOCALITY
Certified
Py is filed with the county building inspection
Q LOCALITY N. OF LAS TUNAS, S. OF WOODROOF moss ST
department. .
D3IC Appllca III___—__ -- NEAREST 1 1 n DISTRICT NO. GROUP TYPE CESSED BY
GROSS ST. WOODROOFD� / CONS .
C ERTIFICATE OF EXEMPTION FROM WORKERS' A I LEGAL .1
CO"(PENSA-170N iNSURANCE DESCRIPTION LOT NO. BLOCK MAP7 HIGHWAYNO STATE MAJOR SECOND LOCAL
NO. (CIRC LC)
(This section need not be completed if lite Work involved TRACT NOWOON LOT S. USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars-(SI00) or less.) USK or
S-
icertify that in the performance of the work for which this SIZE OF LOT EXISTING BLDGe
permil is issued, I shall not employ any person in any manneXX' OWNER of building CHARLES JACKSON =�
u+ as to hrct+nue stthjrct to tilt Workers't'nsnpensgtiran taws. MAIL OCCUPANCY GROUP D
ADDRESS 6342 N. TRELAWNEY AVE.
C')
Date.___ Applicant—.__._.— w
L.
N0110E I'() APPLICANT: If.after making this Certificate of 1 CITY TEMPLE CITY NO. (818) 285-1462 OCCUPANT LOAD cin
I•:remption, you should become subject to the Workers APPL{CATtON FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth-
uitlr comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION[] NO Spec. ICnowi,
deemed revoked. ❑
LIOCCUPANCY INSPECTION❑ Panic Devices
LICENSED('UN'i'RAC'1'URS DECLARATION
I hereby affirm that i ant licensed under provisions of Chapter SAFETY PERMIT[] (LIST ITE
9 (commencing with Section 7000) of Division 3 of the Busi- MS BELOwI
No.OF EXITS
Hess and Professions Code,and my license is in flet(fore anX r'� �7
effect. Name of business PARKING RSq'b ! J p,ROVrDED
SPACES tTM
License Number. _ _ Lic.Class
CAT. WEST SUPIPT.Y.110-
LIMITED TIME USE
Contractor .. ._ .._._.._ .... Date—_----
O ATE OA TC
i and exempt from the licensing requirements as 1 am a FROM. TO:
•
licensed architect or a registered professional engineer. SIZE OFryo.OF 7 INSPECTORS
` 6
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. APPROX. 900 SFX RIES SIGNATURE
inessand Professions C:ode). FINAL APPROVAL
�1n
Lia or Reg.Na._ ._._._ _ Date PRESENT USE OF BUILDING NONE
n An
IlO"ll:OWNER-1111ILDER i)ECLARATION NO. OF EXISTING BUILDINGS V,b
ON LOT AND USE
1 hereby ai7inn that tam exempt fmm the Contractor's it
License Law for file following reast+n (,Section 7031.5. Busy- i
ness and Professions Code): NO. PARKING
1, as owner of file property, will do the work and the SPACES PROVIDED
i
structure is not intended or offered for sale (Section i
7044,Business and Professions Code).
}}
C ONSTRUC:'1'ION LENDING AGENCY PROPOSED USE OF BUILDING 7
1 hereby affirms that there is a construction lending agency PIPE AND FITTINGS
for t{te performance of lite work for which this permit is t
issued(Sec.3097,Civ.C.).
rI
L.cndcr's Name__.._,......_.----_--••_—_-- .I `= � �.
PROPOSED MAX*OCC. ,t
Lender's Address _. .. _. ..-_
PERMIT FEE
t certify that 1 have read this application an
d state that the
above inforntalion is correct.1 agree to comply with all County ISSUANCE FEE 1 -
ordinances and Slate laws relating to building construction, I i Ti:and hereby authorize representatives of this County to enter i TOTAL FEE 25.00 k .;
upon fhc about m nIittned prtaperty for inspection pi rposeS.
I XX SEE:REVERSE FOR EXPLANATORY LANGUAGE
•n Iluu•„1 frim' IPI 1a:1 t• i
i
+�I WORKERS'COMPENSATION DECLARATION �ISM444
CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS A-INGELtES BUILDING AND SAFETY DIVISION I I
insure, or a certificate of Workers'Compensation Insurance,
e,or
>�1 a certified copy thereof(Sec.3800,Lab.Q.
�LLJJ Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING
ADDRESS LOCALITY
0 CerCepa tmeied npy is filed with the county building inspection LOCALITY Temple City NEAREST ST.
Date Applicant NEAREST OISTRI NO GR TYPE MESSED BY
CROSS ST. CONST.
` CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL � GLL�
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
ND. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF SLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
iSIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner OWNER Johnson
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP1Z:1
ESS � ,
J Date ADDRI
Applicant
NOTICE TO APPLICANT: If,after making this Certificate of CITY 3 Z T L. b/7SqCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- (17b APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑
` deemed revoked. F] ❑ No Spec. Knowl.
I LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION XX Panic Devices
I I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT
9 (commencing with Section 7000) of Division 3 of the Busr ❑ (LIST ITEMS BELOW) NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. PARKING REp'D PROVIDED
License Number SP'A CES Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. so
STORIES SIGN RE
iness and Professions Code). FINAL APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING Z.
I HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS W1
ON LOT AND USE � I �. �_
I hereby affirm that I am exempt from the Contractor's +}�
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING 0
I, as owner of the property, will do
PROVIDED do the work and the O.
structure is not intended or offered for sale (Section -
�.I 7044,Business and Professions Code). p
CONSTRUCTION LENDING AGENCY X PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 10
issued(Sec.3097,Civ.C.).
Lender's Name
Yr Lender's Address
PERMIT FEE 25.00 PROPOSED MAX. OCC.
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL.FEE 25.00
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
s
' Signature of Permittee Date
.J